Total number of playing days including games, practices and tournaments (for period of coverage) (10)

Will participants stay overnight?

Yes

No

If you require coverage for more Sports/Activities
than specified above, please contact us

If you suspect an athlete has a concussion, do you have an action plan that includes:

Immediately removing the athlete from play or practice

Yes

No

Keeping the athlete out of play or practice util they provide written clearance from a licensed physician

Yes

No

Do you maintain a system for your sporting activities that includes communication (in written or electronic form) of education materials to participants, parents and coaches about the nature of risk of concussions, including but not limited to information such as: focusing on prevention and preparedness to keep athletes safe; understanding concussions and potential consequences of the injury; reconizing concussion symptoms and how to respond; and learning about steps for returning to play after a suspected concussion?

Yes

No

Do you have any other insurable Athletic Activities not mentioned above?

If you require certificates for more Additional Insureds
than specified above, please contact us

Basic Coverage Summary

Individuals Covered

All players, managers or coaches of the Policy holder

Activities Covered

While participating as a member of the team in a scheduled game,
an official tournament game, or in a practice session of the team;
or travelling directly to or from a game or practice session as a member of the team

Rates Contemplate

All policies are subject to minimum premiums

All standard terms, conditions and exclusions apply

Coverage cannot be back dated

Coverage Limits

General Liability:

$1,000,000 Per Occurrence / $3,000,000 Aggregate

Accident Medical:

$10,000 AD&D / $25,000 (or as selected) Acc Med Benefit

Optional Liability Coverages (Additional Premium Will Apply)

Please select desired optional coverage(s).

Abuse/Molestation Coverage

This endorsement covers the LEGAL COSTS TO DEFEND AGAINST the accusation OF ABUSE OR MOLESTATION against a member of your organization. Basic Abuse/Molestation Coverage of $5,000 per occurrence / $10,000 aggregate is included in the base General Liability Package. Higher COVERAGE Limits FOR Abuse / Molestation can be added for an additional premium as indicated below:

$25,000 / $50,000 Abuse/Molestation

$620.00 (estimate)*

$50,000/$100,000 Abuse/Molestation

$682.00 (estimate)*

$100,000/$500,000 Abuse/Molestation

$744.00 (estimate)*

$1,000,000/$1,000,000 Abuse/Molestation **

$806.00 (estimate)*

$1,000,000/$2,000,000 Abuse/Molestation **

$868.00 (estimate)*

(Higher Limits for) Abuse/Molestation Coverage NOT REQUIRED

* May be more, depending on number of participants. Additional premium Fully Earned at Policy Inception.

Is there a verification procedure for personal auto coverage and personal use reimbursement?

Yes

No

Does the applicant have a driver safety program?

Yes

No

Do employees and/or officers and partners lease or rent autos on the applicant's behalf?

Yes

No

What is the number of autos leased (for the coverage period)

What is the average term of the lease (days)

What is the number of autos rented

What is the average term of rental (days)

How are the leased or rented vehicles used by the applicant?

Are only private passenger type autos leased or rented?

Yes

No

If No, what type? (check all that apply)

Transport Van

Bus

Other

Explain:

Under whose name are the autos leased?

How did you find out about SportInsurance.com ?

Please specify:

Important Notice

For your protection Arizona law requires the following statement
to appear on this form. Any person who knowingly presents a false or
fraudulent claim for payment of a loss is subject to criminal and civil
penalties.

Any person who knowingly and with intent to defraud
any insurance company or other person files a statement of claim containing
any materially false, incomplete or misleading information or conceals,
for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime and may be
prosecuted under state law.

Any person who knowingly and with intent to defraud
any insurance company or other person files a statement of claim containing
any materially false, incomplete or misleading information or conceals,
for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime and may be
prosecuted under state law.

For your protection California law requires the following to
appear on this form: Any person who knowingly presents a false or fraudulent
claim for the payment of a loss is guilty of a crime and may be subject to
fines and confinement in state prison.

It is unlawful to knowingly provide false, incomplete, or
misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include
imprisonment, fines, denial of insurance and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false,
incomplete, or misleading facts or information to a policyholder or claimant
for the purpose of defrauding or attempting to defraud the policyholder or
claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado division of insurance within
the department of regulatory agencies.

WARNING :Any person who knowingly and with intent to injure,
defraud, or deceive any insurer files a statement of claim or an application
containing any false, incomplete, or misleading information is guilty of a
felony of the third degree.

Any person who knowingly, and with intent to defraud or deceive any
insurance company, files a statement of claim containing any false,
incomplete, or misleading information is guilty of a felony.

Any person who knowingly or willfully presents a false or
fraudulent claim for payment of a loss or benefit or who knowingly or
willfully presents false information in an application for insurance is
guilty of a crime and may be subject to fines and confinement in prison.

Any person who, with a purpose to injure, defraud, or
deceive any insurance company, files a statement of claim containing any
false, incomplete, or misleading information is subject to prosecution and
punishment for insurance fraud, as provided in RSA 638:20.

Any person who knowingly files a statement of claim containing
any false or misleading information is subject to criminal and civil
penalties.

Any person who knowingly and with intent to
defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information
or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties.

Any person who knowingly and with intent to
defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information
or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime and
subjects such person to criminal and civil penalties.

Any person who knowingly, and with intent to injure, defraud
or deceive any insurer, makes any claim for the proceeds of an insurance
policy containing any false, incomplete or misleading information is guilty
of a felony.

It is a crime to knowingly provide false,
incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines
and denial of insurance benefits.

It is a crime to knowingly provide false,
incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines
and denial of insurance benefits.

Any person who knowingly presents a false or fraudulent claim for
payment of a loss is guilty of a crime and may be subject to fines and
confinement in state prison.

Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of
claim containing any materially false information, or conceals for the
purpose of misleading, information concerning any fact material thereto,
commits a fraudulent insurance act, which is a crime, and shall also be
subject to a civil penalty not to exceed five thousand dollars and the
stated value of the claim for each such violation.

Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines
and confinement in prison.

DECLARATION

To the best of my knowledge and belief all statements made in this Application for Insurance are true.
Signing of this document does not bind the Applicant to complete the insurance,
but it is agreed that this Application shall be the basis of the contract,
should a policy be issued.